Desire for Assistance / Urgent Needs Questions

AAFP Social Needs Screening Tool

Would you like help with any of these needs?
Yes/ No

Arlington Screening Tool

Are any of your needs urgent?
For example, I don’t have food for tonight, I don’t have a place to sleep tonight, I am afraid I will get hurt if I go home today.

If you checked YES to any boxes above, would you like to receive assistance with any of these needs?

Boston Medical Center-Thrive Screening Tool

Would you like help connecting to resources?  Please circle below.  
Housing/ shelter
Food
Paying for Medicines
Transportation to Medical Appointments
Utilities
Child care/ day care
Care for elder or disabled
Job search/ training
Education

Health Leads Social Needs Screening Toolkit

If you checked YES to any boxes above, would you like to receive assistance with any of these needs?
Yes/No

Are any of your needs urgent? For example: I don’t have food tonight, I don’t have a place to sleep tonight.
Yes/No

Kaiser Permanente's Total Health Assessment for Medicare Members

If for any reason you have difficulty or cannot do one or more of these activities of daily living, do you get the help that you need?
I get all the help I need
I could use a little more help
I need a lot more help
I don't need any help

North Carolina Medicaid Screening Tool

Are any of your needs urgent? For example, you don’t have food for tonight, you don’t have a place to sleep tonight, you are afraid you will get hurt if you go home today.
Yes/ No

Would you like help with any of the needs that you have identified?  
Yes/ No

Kaiser Permanente's Your Current Life Situation Survey

If for any reason you need help with activities of daily living such as bathing, preparing meals, shopping, managing finances, etc., do you get the help that you need?
I don’t need any help
I get all the help I need
I could use a little more help
I need a lot more help

Which of the following would you like to receive help with at this time? (Select ALL that apply)
Food
Housing
Transportation
Utilities (heat, electricity, water, etc.)
Medical care, medicine, medical supplies
Dental services
Vision services
Applying for public benefits (WIC, SSI, SNAP, etc.)
More help with activities of daily living
Childcare/other child-related issues
Debt/loan repayment
Legal issues
Employment
Other
I don’t want help with any of these

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